Provider Demographics
NPI:1790490829
Name:MADERA-VASQUEZ, EIDEN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:EIDEN
Middle Name:
Last Name:MADERA-VASQUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9379 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2034
Mailing Address - Country:US
Mailing Address - Phone:909-843-0169
Mailing Address - Fax:
Practice Address - Street 1:2928 E CESAR E CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-3110
Practice Address - Country:US
Practice Address - Phone:323-266-6700
Practice Address - Fax:323-266-7161
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW995171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical